Animal bites management in Northern Iran: Challenges and solutions

Objectives Animal bite is considered a serious social, economic, and health risk for societies with poor animal bites and population management. The objective of this study was to propose a model for animal bites management in Golestan Province. Methods The present study is a multi-method study conducted quantitatively and qualitatively. First, as a cross-sectional study, the animal bites in Golestan Province and the country were calculated and their trend was predicted. Secondly, in the qualitative study (content analysis), the challenges, barriers, and methods of animal bite control were extracted through conducting semi-structured interviews and focused group discussion meetings. Finally, the model of animal bite management was developed and it was confirmed by Round Delphi. The data were analyzed via content analysis using MAXQDA18. The participants in this study consisted of university professors, managers, and executive officers involved in animal bite and rabies control plans. Results This study revealed that the animal bite in Golestan Province had an upward trend, as in the country, and dogs were the main cause of bites (90%). The obstacles and challenges of current animal bites control program in eight areas were expressed by the participants. Also, the animal bite management model, which was obtained from the data of different stages of this study, included nine fields and 41 sub-fields. The fields of the animal bite management model included: providing a cultural package, resolving barriers to animal population control plans, wide coverage of dog vaccination, passing and enacting preventive laws, attracting financial support, constructing standard equipment, providing proper medical services, enhancing inter-departmental coordination, and controlling rabies in the wild. This model was confirmed in a Delphi round. Conclusion Our study indicated that Golestan Province with an average bite higher than twice the country's average is one of the leading provinces in this regard. Thus, revising the animal bite and animal population control plans in this province is necessary. The model designed in this study can be used as a practical guide by policy makers and officials to manage animal bite and related consequences in this province.


Introduction
Animal bite has been considered a serious social, economic, and health risk for societies that have poor management in the field of animal bite and population management. The ascending trend of the dog population as one of the most important factors of human bites on the one hand and the growing number of animal bite cases on the other in some societies have caused an increase in these risks.
Dog bite is an important index of society safety. This is a key index as it describes both effects on public health risks as well as risks to livestock and wildlife, including bites and threatening behavior towards people and other animals. Dog bite injury is one of the most important causes of complications, especially in children, leading to the high rate of hospitalization and significant psychological damage even without the threat of rabies [1,2]. Free-roaming threatening dogs also affect the livability of society by restricting people's freedom to move around their neighborhoods and preventing physical activity [3]. Also, they make the urban face ugly due to the re-scattering of garbage in the city and village, which itself is the basis of disease transmission.
Millions of people are bitten by animals with about 10 million people bitten by animals in the world treated for rabies prevention annually [4]. Dogs are the most important cause of rabies transmission to humans, and this virus kills approximately 59,000 people in the world every year, most of which occur in African and Asian populations [5]. The Asian continent constitutes a significant percentage of the disease burden in developing countries at a high cost; the total cost caused by rabies transmitted by dogs in Central Asia and the Middle East is 8.6 billion dollars. More than 99% of rabies in humans occurs due to the transmission of the virus through the bites of dogs infected with the virus [6].
In Iran, the cases of animal bite have increased over the last 30 years from 18,305 cases (with 35 cases per hundred thousand population) in 1987 to 168,511 cases (with 177 cases per hundred thousand population) in 2016; through timely measures, the ratio of human rabies cases to the animal bite has diminished. However, the number of animal bites in the country is still increasing [4]. Based on the latest status of animal bite in Iran, the highest number of animal bites has been reported in Golestan, Ardabil, North Khorasan, as well as Chaharmahal and Bakhtiari Provinces [7].
In Golestan Province, the growing trend of animal bite on the one hand has increased health risks and incurred high costs of rabies post-exposure prophylaxis (PEP), and on the other hand, it has imposed social and psychological consequences on society. It is expected that in the absence of appropriate intervention and with continuation of the current process, in addition to the damage caused to society, we will witness an increasing need for more resources and subsequently their waste to control the disease in this sector of the health system. Thus, given the lack of previous studies on animal bite management in Golestan Province and the recent recommendations of the World Health Organization (WHO) regarding the regional management of this disease, the objective of this study was to provide a model of animal bite management in Golestan Province.

Study design
The present study is a multi-method study conducted quantitatively and qualitatively between 2020 and 2022. First, as a crosssectional study, the animal bite in Golestan Province and the country was calculated with its trend predicted for the coming years. The data were collected via the data extraction form of the Ministry of Health and Golestan University of Medical Sciences for the past decade (between 2011 and 2021). Following analysis, the trend of animal bite incidence for Golestan Province and the country of Iran was drawn using Excel.
Secondly, qualitative study was conducted in three phases. In the first phase of this qualitative study, the challenges, barriers, and methods of animal bite control were extracted by conducting semi-structured interviews (SSI) and focused group discussion meetings (FGD). The interviews were performed based on the interview guide form as a data collection tool, where the participants, after becoming informed of the objective and process of the study as well as receiving a summary of information from the previous stages of the study, expressed their opinions on challenges and barriers to animal bite control plus their solutions. All meetings were recorded as audio files with the consent of the participants with notes taken at the same time. In the second phase of the study, the data obtained previously were reviewed, and corrected by experts during two roundtable discussion sessions, whereby the initial model was obtained.
Finally, the Delphi technique was used to validate the animal bite management model. The data collection instrument was a questionnaire which was based on the identified dimensions and components sent to the participants via email. In this questionnaire, content validity and modified kappa were used to confirm the validity of the model.

Study participants
In this study, the participants were purposefully selected to have the most and richest information as well as to be able to provide their information appropriately to the researchers, with interviews conducted until the data were saturated.
The participants in the interview included 18 managers and experts involved in animal bite control, rabies and animal population management plans (such as the managers and executers of the Environment Department, the Provincial Veterinary Department, the Department of Human and Animal Diseases of the Ministry of Health, Governor's Office of Urban Affairs, Organization of Municipalities and Villages of the country, elected mayors of Golestan Province, etc.). The participants in the focus group meetings included 55 villagers and representatives of non-governmental animal protection institutions. The participants in Delphi stage included 19 university professors, officials, and executive experts of organizations involved in animal bite and rabies control plans.

Data analysis
In this research, the data collected from the semi-structured interviews (SSI) and focused group discussion meetings (FGD) were analyzed via the content analysis method and using MAXQDA18 software. Also, for the Delphi questionnaire, content validity and modified kappa were applied to confirm the validity of the model.

Results
This study revealed that the number of animal bites in Golestan Province increased from 503 cases per hundred thousand population in 2011 to 744 cases per hundred thousand population in 2021. The animal bites in Iran also increased from 179 cases per hundred thousand population in 2011 to 313 cases per hundred thousand population in 2021. Finally, the prediction of animal bites for the coming years in Golestan Province shows a growing trend as in Iran. Fig. 1 displays the trend of animal bites in the study years.
In the interview, 13 managers and officials in the organizations involved in animal population and rabies management plans were interviewed. Also, the opinions of 12 representatives of animal protection institutions and 23 villagers were collected through holding two 3-h focused group discussion meetings (FGD).
According to the opinions, the challenges of animal bite management plans consisted of eight fields, including low interdepartmental cooperation and coordination, frequency and diversity of animals and wide climate, lack of animal handling skills and responsibility, implementation problems of the animal population management plans, unsafe construction, environmental threats, weak laws, as well as double use of medical resources and services. Table 1 reports the challenges and barriers to animal bite management plans in Golestan Province.
Secondly, the data obtained previously were reviewed and corrected by experts during two meetings, where the initial model of animal bite management in Golestan Province was obtained. This phase was conducted by holding two special meetings by the expert panel with the participation of six experts in the field of animal population and bites, as well as rabies management. Further, the initial model entered the Delphi round for validation. Using the Delphi technique, the questionnaire was sent to 23 experts in country, which was answered by 19 experts. After performing the first round of the Delphi technique, the model was finalized in all dimensions of the questionnaire (modified kappa (K) > 0/77, content validity ratio (CVR) > 0/55).
The final model of animal bite management in Golestan Province included nine fields (providing a cultural package, resolving barriers to animal population control plans, wide coverage of dog vaccination, implementation and development of preventive laws, attraction of financial support, construction of standard equipment, correct provision of medical services, increase of interdepartmental coordination, control of rabies in the wild) plus 41 sub-fields. Fig. 2 demonstrates the proposed model of animal bite management in Golestan Province.

Discussion
Our study indicated that the number of animal bites in Iran increased from 179 cases per hundred thousand population in 2011 to 313 cases per hundred thousand population in 2021, and in Golestan Province, the number of animal bites rose from 503 cases per hundred thousand population in 2011 to 744 cases in 2021 per hundred thousand population. The prediction of the trend of animal bites in the coming years also indicates the rising trend of animal bites in Golestan Province and Iran. According to the report of the World Health Organization (WHO), more than ten million people are bitten by animals in the world every year, with the two continents of Asia and Africa claiming the highest number of animal bites [8]. The results were consistent with the data of our study. According to the results, it can be stated that the number of animal bites in Golestan Province, as with the trend of animal bites in the country, has an upward trend and is more than twice the national average. The high number of animal bites in this province can be due to the fact that this province is located in the center of livestock management and agriculture in Iran, which naturally increases the exposure of humans and animals.

Providing a cultural package
One of the important challenges raised in this study was the lack of proper animal handling skills and responsible animal maintenance in society. A study conducted showed that society participation played an effective role in the health and population management of dogs [3]. According to the reports of the WHO, training and information about responsible pet ownership, training on dog behavior and bite prevention, and immediate care measures after a bite increase the awareness of society on animal bite prevention and rabies control [9]. The national studies have reported that training is effective on reducing the number of animal bites [10]. These data were in line with the results of our study. In this regard, the field of cultural package was developed with six sub-fields. This field focuses on enhancing the behavioral skills of society with animals, explaining the responsible ownership, changing the purely emotional views of society as well as promoting a single health view among the officials and society, which can provide the necessary background for the cultural improvement of society, thereby reducing the number of animal bites in Golestan Province.

Resolving barriers to animal population management plans
The existence of several barriers to developing, updating, and implementing animal population management plans was one of the other challenges raised in this study. The national and international studies have shown that dogs are the main cause of bites in most areas [9]. In the study area, dogs were the cause of 89% of bites, which was consistent with global data. Specifically, 59% of attacking dogs had owners while 41% were stray dogs. Thus, it can be expected that with the dog population management, a large number of the bites and related costs in Golestan Province will be reduced. In this regard, the field of resolving the barriers to animal population management plans was developed with six sub-fields focusing on increasing the quality and quantity of breeding and sterilization centers, determining the operational criteria (for handing over, releasing, killing mercy, etc.) with the participation of the public sector and non-governmental organizations for societal accompaniment and alignment. -Studies have shown that among the dog population management plans, sterilization is one of the most effective methods and, along with other methods, it can reduce the dog population [3,11,12]. In addition to lowering the population of dogs, sterilization can reduce the geographical range of dogs roaming and the number of attacks on humans [13][14][15]. These results concurred with the recommended measures of our study.

Wide coverage of dog vaccinations
Manifestations of rabies virus infection in some animals are associated with an increase in aggressiveness in the animal, which augments the number of animal bites. Meanwhile, due to the high lethality of this disease, if the attacking animal is not vaccinated, prevention services should be provided for the victims post-exposure, which involves a high cost [16].
Many studies conducted in continental Europe and America have shown that dogs have adequate vaccination coverage [17]. The results were not in line with our results, however. The results of our study revealed that uncertainty about the safety level provided in dog vaccination plans in the past years has been raised as a challenge by those in charge. This means that the lack of proper vaccination coverage of dogs as the main cause of animal bites in humans increases the number of animal bites, while also causing loss of resources to provide prevention services for animal bite victims.
Disease models and real-world experiences around the world show that sustainable vaccination coverage of 70% of the dog population is sufficient to prevent disease transmission among dogs and from dogs to humans, and is a proven as well as cost-effective way [9,18]. As such, broad coverage of vaccination of dogs with six sub-fields was discussed with a focus on providing and continuously monitoring the appropriate level of safety in dogs, marking vaccinated dogs and providing an animal safety registration system with the access of prominent and relevant organizations.

Passing and enacting preventive laws
In many countries, special laws have been passed regarding the responsible ownership of animal owners to protect the health of animals and society against possible threats, as along with legal and ethical expectations for the implementation of dog population management plans by animal owners. Even in the laws of some countries, a dog does not have to bite someone for the owner to have committed an offense. If the dog's behavior is aggressive or threatening, the owners of the animal may be prosecuted [3,9]. The results were not consistent with the findings of our study, and this unimportant category of laws plus their lack of deterrence in our study were repeatedly raised by the people in charge of the animal population and bites management plans as an important challenge. Accordingly, the field of passing and enacting preventive laws was developed and approved with five sub-fields. In this field, it has been attempted to use the potential of the council of representatives of the provincial parliament to explain the appropriate bills to enhance the deterrence of laws and the legal dimensions of responsible ownership of animals. Also, by holding necessary coordination meetings for the judges of province, the necessary executive procedure for the current laws should be established.

Rabies control in the wild
The climate and extent of forests, diversity of animal species, presence of numerous villages in these areas, province's border with neighboring countries, etc., all have been raised in the results of our study as the challenges of rabies control in the wild. Our study revealed that in addition to all measures for controlling animal bites and rabies in domestic animals, these measures will provide the desired outcome when the cycle of the rabies virus in wildlife is controlled. This is because there is the threat of virus transmission from wildlife to other domestic mammals. Thus, one of the fields that plays an effective role in controlling rabies and animal bites and subsequently managing its cost is the area of rabies control in the wild. Accordingly, this field with three sub-fields focuses on continuous monitoring of the rabies virus cycle in wildlife and breaking the transmission chain between wild and domestic animals.
Studies have shown that many European countries are free from rabies and other European countries often control rabies in dogs, and focus on controlling rabies in wildlife including bats, and foxes as well as preventing from entering from the border of other countries. To control rabies in the wildlife, some of these countries use an oral vaccine that is dipped in food bait, distributed to the target areas using airplanes; in their documents, they emphasize the use of oral vaccine in wildlife [9,19,20]. The results of our study were not in line with these findings and there was no effective plan in this field by the Environment Protection Organization of our country. Thus, addressing this field as well as reviewing and developing appropriate plans in the country's Environment Protection Organization will play an effective role in controlling rabies, animal bites, and subsequently related costs.

Correct provision of medical services
Among the proposed fields of the above model, the only field in which the measures and its sub-fields were dominated by time was related to post-exposure and animal bites, to reduce the health and economic consequences of animal bites. This field focuses on providing medical services according to the type of bite and the attacking animal, as well as the safety of the attacking animal to avoid the loss of resources.
In the documents of the WHO, the transmission of rabies through the bite of rodents is mentioned with an unknown term and not confirmed, while in another report, the provision of services other than washing and disinfection is considered unnecessary for bites from domestic mice. For wild mice, it is also necessary to consult an infectious diseases specialist [9,21]. Our results revealed that measures are also taken for rodents, which does not concur with the global data. In this regard, it is necessary to conduct further studies to resolve the ambiguity of whether rodents can be vectors in Iran.
Scientific documents have reported that if the attacking animal looks healthy plus normal and the level of safety of vaccinated animals, especially dogs, is confirmed, there is no need to provide level 2 and 3 services to animal bite victims [22,23]. Other reports published by the Centers for Disease Control and Prevention (CDC) along with the American Veterinary Medical Association (AVMA) also found that a small percentage of people bitten by dogs received rabies PEP [17,24]. The results of our study showed that the provision of medical services to the victims does not depend on the vaccination history of the animals. The results were not in line with the data of America. According to studies, the provision of rabies PEP services regardless of the history of vaccination of invasive animals has imposed a great economic burden on Golestan Province [16], which is caused by the challenge of the Ministry of Health and Medicine's lack of confidence in the level of safety of dogs vaccinated by veterinarians. Therefore, it can be stated that by applying vaccination coverage and providing a suitable level of safety in dogs that have the highest number of bites, in addition to reducing animal bites, the high costs of providing PEP level 2 and 3 services to victims can be significantly reduced.

Financial support
Our study indicated that the lack of a clear and continuous dedicated budget for the implementation of animal population management and animal bite control plans is an important challenge for governmental and non-governmental organizations. Another challenge of this field is some people profiteering under the title of animal protection organizations, fewer facilities and low income of some municipalities to implement the plans of breeding, sterilization, and keeping animals.
This field focuses on the credit in the budget through the Planning and Budget Organization based on the potential of the Council of Representatives of the Provincial Parliament to provide the necessary platform for long-term and continuous planning. Also, regarding attraction of public financial support by non-governmental organizations, the lack of trust in plans and the fear of profiteering by managers plus the public sector have been raised as a concern. In this field, it is possible to receive help for the financial transparency by providing monitoring plans on behalf of these organizations. Another challenge raised was the low potential of small-town municipalities to generate the necessary income for the implementation of these plans. In this field, along with the follow-up of dedicated budget for plans, it is possible to use the potential of the municipalities of several nearby cities to establish joint sterilization and maintenance centers. It is also possible to employ additional economic evaluation studies for cost-benefit estimation of proposed solutions for justifying managers and policy makers as well as for cost-benefit calculation of actions to attract dedicated budget.

Standard construction
Our results revealed that one of the challenges of animal bite prevention in Golestan Province is the absence of walls or fences around houses. In the construction culture of the Turkmen-inhabited rural areas of Golestan Province, walls between houses are seldom used, which facilitates the animal bites. For standard construction, one of the suggested sub-fields is to use the potential of the Housing Foundation as the trustee of the construction of rural areas. With the requirement to build a suitable wall or fence around the houses to issue the completion certificate, expectedly if there is an attacking animal, the probability of animal bites will diminish. Also, another important sub-field of this field is explaining the standard of keeping animals in homes and around the village as herding dogs. This is because one of the threats in the village and its surroundings is the herd dogs, which urgently needs to be organized. In this regard, along with promoting the culture of responsible ownership, the rules of keeping animals can be explained with the participation of the responsible organizations. Another challenge raised in our study was the open location of the waste depot. According to the environmental authorities, on the one hand, these places are suitable places for feeding stray dogs, which itself transmits diseases and the increase in the population of stray dogs. Meanwhile, due to the proximity of these centers to wildlife, it causes them to cross and create new hybrid species between wolfs and dogs, which are far more aggressive. Thus, one of the proposed sub-fields in this field is the enclosure of waste depots.

Increasing interdepartmental coordination
In Iran, the responsible institutions for rabies control, animal population management, and animal bite control are the Ministry of Health and Medicine, Veterinary Medicine, Environment, Ministry of Interior and Municipalities. In this regard, the Ministry of Health has taken steps to prevent and control rabies. The defined duties of other organizations regarding the rabies prevention and control plans include establishing a headquarters for the demolition of harmful animals (dogs and cats) and preparing the relevant plan as well as notifying the governorates by the Ministry of Interior, planning and action to fight with rabies in the wild by the Environmental Protection Organization, as well as preparing a plan to identify, vaccinate, and collar domestic dogs and herds by the country's veterinary organization [25]. The results of our study revealed that one of the challenges of the institutions in charge of the province is low interdepartmental coordination, lack of continuity of inter-departmental meetings until consensus is reached, absence of a central role of the organization in charge of coordination in the province, inaccurate monitoring of the progress of the plan and the explanation of the application model according to the characteristics of the province. In this regard, one of the important and effective fields of animal bite control is enhancing interdepartmental coordination. This field focuses on the responsible organizations, while acknowledging the problem and selecting an organization as the responsible authority of coordination for the unity of approach, taking action regarding the formulation, implementation, and periodic monitoring of dog population management (DPM) interventions. It can be expected that by explaining the duties of each organization and holding continuous meetings to resolve the barriers and to evaluate the progress of the plans, the animal bites and its related consequences will decrease in Golestan Province.

Conclusion
Golestan Province is one of the provinces with the highest number of animal bites, with an average animal bite more than twice the average of the country. Given the growing trend of animal bites in Golestan Province plus the economic, social, and health consequences, it is necessary to review the rabies, animal bites, and animal population management plans in this province. The model designed in this study can be used as a practical guide for policy makers and provincial officials to manage animal bites as well as related consequences in Golestan Province. We hope that with the above fields, the rising trend of animal bites in the province will decline and in addition to preventing health risks, the economic and psycho-social damages of this phenomenon will also be prevented.

Ethics statement
This study was conducted with permission from the Ethics Committee of Iran University of Medical Sciences with the code of ethics IR. IUMS.REC.1398.716 approved in 2018. In this study, the principle of data confidentiality was observed and the interviewees entered the study with their consent.

Author contribution statement
Vahid Bay: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.
Irvan Masoudi Asl: Conceived and designed the experiments; Analyzed and interpreted the data; Wrote the paper. Mohamad Reza SHirzadi, Mehdi Jafari sirizi: Contributed reagents, materials, analysis tools or data; Performed the experiments.

Data availability statement
Data will be made available on request.

Additional information
Supplementary content related to this article has been published online at [URL].